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nneni* <br /> Safety and Buildings Division <br /> et■�nF.r. SANITARY PERMIT APPLICATION Bureau of Building Water System! <br /> 201 E.Washington Ave- <br /> In accord with ILHR 83.05,Wis.Adm Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> •. Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. 6l <br /> • See reverse side for instructions for completing this application St a Sanitary Permit Number �u <br /> The information you provide may be used by other government agency programs ❑Check �ision to previous application XJ <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> OXIVILLE /11OR91S 1/4 1/4,S T,41 N, R SE(or <br /> Propert Owner's Mailing Address Lot Nu*'let Block Number <br /> .gio6 Sc sr. v -6 , <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> F Lfl <br /> ,<A, <br /> ( c5�344•I SD <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms ?' ❑ TowVilla9 OF IX' /Q. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 432' SZ—Iq 0,7— JOD <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. 10 New 2. [:] Replacement 3. ❑ Replacement of 4_ [:] Reconnection of 5. E] Repair of an <br /> - _ --- ------ ---- "--System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13E]Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Final Grade <br /> Required(sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) El7.evation <br /> '2>00 2-1 Z •7 '^ - O •9 Feet (0,o Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab. Site Fiber- plastic Exper- <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existin strutted <br /> Tanks Tanks ,� 1� <br /> Septic Tank or Holding Tank D so O ' r5 f} <br /> Lift Pump Tank/Siphon Chamber El ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No S raps) MP/MPRSW No.: Business Phone Number: <br /> ARp lois 3 G IS•8� - SIS <br /> PI tier's Address(Street,City,State,Zip Co ): ' 1 <br /> IX. COUNTY/DEPARTMENT USFONLY <br /> ❑Disapproved Sanitary Permit Fee OncludesGroundwater Date Issued IssuinciAgent Signature(No Stamps) <br /> 9kp <br /> proved ❑Owner Given Initial 71 <br /> Surcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/99) DISTRIBUTION: Original to County,One copy To: Safety 8 Ruildin9s Division,Owner,Plumber <br />